CLM-2026-031607
Lakeside Behavioral Health, Behavioral Health. Service 2026-09-21 at office (POS 11). Received 2026-09-24.
Member
Resolved through the identity graph
- Member
- Wayne Castro
- Member ID
- UHC-05335-91
- Date of birth
- 1950-09-06
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-417736
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-4266
- Coverage period
- 2022-11-01 to present
- Deductible
- $2,279.13 of $3,500.0065%
- Out-of-pocket maximum
- $565.56 of $7,000.008%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 2763853613
- Network
- Out of network
- Rendering NPI
- 1648057663
- Location
- Austin, TX · TIN 90-0644488
- Authorisation / referral
- none / REF356876
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 90834 | Psychotherapy, 45 minutes | — | 1 | 1 | $172.00 | $77.40 | — | — | DeniedCO204 |
| 2 | 90791 | Psychiatric diagnostic evaluation | — | 1 | 2 | $355.00 | $159.75 | — | — | DeniedCO204 |
| Totals | $527.00 | $237.15 | — | — | ||||||
- 1. F90.2 ADHD, combined typeprincipal
- Patient account
- PA-427489
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009948 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-09-21: NAVIGATE-HMO (HMO), effective 2022-11-01. | |
| Timely filing | Pass | Received 3 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Fail | CO204 | Billing provider 2763853613 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Behavioral Health2026-09-21 16:30
Patient seen for adhd, combined type.
- SystemSystem: Claims system2026-09-24 02:25
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 2763853613 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000772 | 2026-08-27 | Mesa Dermatology Clinic | $918.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
No out-of-network benefit on this plan.